Medicare Enrollment Updates

Overview

The Annual Coordinated Election Period (ACEP), from October 15 through December 7, 2018, is the time period during which Medicare beneficiaries can enroll in, switch, or disenroll from Medicare Advantage (MA, or Part C) plans and Part D prescription drug plans.  Elections made during this time period will be effective January 1, 2019.  Information about 2019 MA and Part D plan offerings is now available on www.medicare.gov, and marketing of such plans has begun.

This CMA Enrollment Alert describes the final 2019 Medicare & You handbook, new online tools produced by the Centers for Medicare and Medicaid Services (CMS) and their drawbacks, information about 2019 MA plans, and changes in enrollment periods.

Medicare & You 2019 – Final Draft Improved

Since Fall 2018, the Center for Medicare Advocacy has highlighted how CMS materials, including the 2018 Medicare & You handbook and outreach and enrollment documents, have encouraged beneficiaries to choose a private Medicare plan over original Medicare instead of more objectively presenting enrollment options (see, e.g., here and here).  

When the draft 2019 Medicare & You handbook (Handbook) was released this May for stakeholder input, the Center and other consumer advocates were alarmed at glaring inaccuracies in the document, which, among other things, perpetuated steering beneficiaries towards MA plans.  As discussed in a previous CMA Alert, in May 2018, the Center joined Justice in Aging and the Medicare Rights Center in writing to CMS about concerns with the draft Handbook. 

As our organizations asserted at the time, rather than presenting information in an objective and unbiased way, the draft Handbook’s information about traditional Medicare and Medicare Advantage (MA) distorted and mischaracterized facts in serious ways.  For example, the draft Handbook:

• Suggested that MA is the less expensive alternative for beneficiaries;
• Failed to highlight the clear distinction between traditional Medicare and MA: Traditional Medicare provides access to all Medicare participating providers nationwide, while MA limits access to a set network of providers in a specific geographic area; and
• Characterized prior authorization requirements in MA plans, which are restrictions on access to services, as a benefit, rather than as what they are: Mandatory hurdles for MA members not required for individuals in traditional Medicare.

After considering our comments and meeting with our organizations, CMS addressed the most serious inaccuracies and omissions in the final version of the Handbook, as discussed in a letter our groups sent to CMS Administrator Seema Verma.

For example, the Handbook no longer references prior authorization in MA plans as a “benefit” rather than a barrier to accessing care and in charts comparing MA and traditional Medicare, appropriately highlights one of the key distinctions between the two coverage options – access to providers, with limited networks in most MA plans.  Additionally, assertions that MA plans are the least expensive alternative for beneficiaries are tempered.

As noted in our letter to CMS, however, more needs to be done in both the Handbook and other CMS materials to ensure that “beneficiaries have access to accurate, understandable information that is presented from a neutral and balanced perspective.” As discussed below, this includes newly launched CMS online tools, which appear to perpetuate inappropriate steering towards private MA plans.

New Online Tools on Medicare.gov – MA Steering Continues

In an October 1, 2018 press release, CMS announced the eMedicare initiative “that will empower patients and update Medicare resources to meet beneficiaries’ expectation of a more personalized customer experience [… and] will modernize the way beneficiaries get information about Medicare and create new ways to help them make the best decisions for themselves and their families.”  As part of this initiative, CMS has launched:

• “An improved coverage wizard to help beneficiaries compare options at a deeper level as a way to decide if Original Medicare or Medicare Advantage is right for them; 
• A stand alone, mobile optimized out of pocket cost calculator that will provide information on both overall costs and prescription drug costs”

As discussed below, however, these tools appear to favor enrollment in Medicare Advantage by providing overly broad, blanket suggestions to enroll in MA plans when much more nuance is required.

The new coverage wizard is located on the medicare.gov homepage via the Compare Coverage Options button.  Until recently, the same link sent you to a 10 question tool that asked a series of questions aimed at helping you figure out whether MA or traditional Medicare would be better for you.  As discussed in the Center’s recent Report on Part C and D changes, these questions included, among other things, a question about chronic conditions that steered people towards an MA plan (see, discussion in the report at footnote 41-42). 

Now the coverage tool has been shortened to the following 5 questions, and, based upon “yes” or “no” responses, provides “results” suggesting either MA or traditional Medicare.  

1. Do you want your Medicare coverage to include prescription drugs?
2. Do you want extra coverage to help pay the 20% of your medical bills Original Medicare doesn't cover?
3. Do you want Medicare coverage for vision and/or dental?
4. Do you travel a lot, or live in another state part of the year?
5. Do you want Medicare coverage for frequent international travel?

If an individual responds “yes” to either 4 or 5 regarding travel or living in another state, the tool appropriately guides you toward traditional Medicare because most MA plans have restricted networks that are limited to a given service area (usually a county).

If you answer “yes” to 2 “Do you want extra coverage to help pay the 20% of your medical bills Original Medicare doesn't cover?” the tool recommends joining an MA plan.  The most obvious answer would be to suggest a Medicare Supplement/Medigap which in almost all cases covers the 20%. However, there is no mention of any other supplemental coverage options, such as Medigap, Medicaid, etc. even though in an MA plan, while there is an out-of-pocket limit, an individual will not have all of their cost-sharing covered. Although Medigap enrollment rights are more limited than opportunities to enroll in MA, Medigaps should be mentioned here as an option, along with the enrollment limitations.  Determining which option is cheaper for an individual – MA vs. traditional Medicare with a Medigap and Part D plan – will depend on a number of factors, including geography, type of plan selected, individual health, and utilization of services. In other words, a blanket response suggesting enrollment in an MA plan is unwarranted and can be inaccurate based upon these variables. 

The second online tool, the out-of-pocket cost estimator (see Estimate Medicare Costs on the medicare.gov homepage) bears this point out.  Without analyzing how these estimates are calculated and their overall accuracy, performing searches in different geographic areas (or even altering the search criteria in the same area) can produce different estimates with respect to whether MA is cheaper than traditional Medicare and a Medigap plus a Part D plan (see, e.g., example in text box below). 

Question 3, which asks if you want coverage for vision and/or dental, directs individuals who answer “yes” to an MA plan. While many MA plans do offer some limited coverage of hearing, vision and/or dental services, such coverage is by no means universal, and varies considerably (see, e.g., a 2016 Health Affairs Blog that provides data on MA enrollees covered by supplemental benefits).  Directing people to MA if they express a desire for “vision and/or dental” has the potential to oversell such coverage available through MA plans, steering individuals to join MA; the coverage tool should at least note such limitations in the answer.  As reported by the Commonwealth Fund in a January 2018 report,

[a]mong Medicare beneficiaries, 75 percent of people who needed a hearing aid did not have one; 70 percent of people who had trouble eating because of their teeth did not go to the dentist in the past year; and 43 percent of people who had trouble seeing did not have an eye exam in the past year. […] Because few people have supplemental insurance covering these additional services, among people who received care, three-fourths of their costs of dental and hearing services and 60 percent of their costs of vision services were paid out of pocket.

While online tools can be helpful, they should not offer shortcuts that oversimplify the decisions an individual must make, particularly if they don’t describe all of the options, such as Medigap plans, in answer to question #2.  CMS should revise these tools accordingly.  Ultimately, online tools should not replace individual, unbiased counseling, such as that offered by State Health Insurance Assistance Programs (SHIPs – see https://www.shiptacenter.org/).

MA Landscape

Information about 2019 Medicare Advantage and Part D plan offerings are now available online at medicare.gov.  In a September 28, 2018 press release, CMS provided information about the landscape of MA and Part D plans available in 2019, including the following excerpts:

• Enrollment in Medicare Advantage is projected to be at an all-time high in 2019 with 22.6 million Medicare beneficiaries. This represents a projected 2.4 million (11.5 percent) increase from 20.2 million in 2018. Based on projected enrollment, 36.7% of Medicare beneficiaries will be enrolled in Medicare Advantage in 2019.
• Nationally, the number of Medicare Advantage plan choices will increase from about 3,100 in 2018 to about 3,700 in 2019 – and more than 91 percent of people with Medicare with have access to 10 or more Medicare Advantage plans in 2019, compared to nearly 86 percent in 2018. 
• The average number of Medicare plan choices per county will increase by 5 plans – up to approximately 34 plan choices per county.
• Due to new flexibilities available for the first time in 2019, nearly 270 Medicare Advantage plans will be providing an estimated 1.5 million enrollees new types of supplemental benefits:
  • Expanded health-related supplemental benefits, such as adult day care services, and in-home and caregiver support services; and
  • Reduced cost sharing and additional benefits for enrollees with certain conditions, such diabetes and congestive heart failure due to the agency’s reinterpretation of uniformity requirements.

With respect to the new types of supplemental benefits described above, the Center recently issued a Special Parts C and D Report that both describes the scope of such benefits, and raises concerns about how their availability might impact consumer decision-making.

Reminder: Enrollment Period Changes 

Pursuant to changes in federal law, the Medicare Advantage Disenrollment Period (MADP), which previously allowed individuals to disenroll from an MA plan during the first 45 days of the calendar year, will be replaced in 2019 with the Medicare Advantage Open Enrollment Period (MA OEP).  During this period individuals already enrolled in an MA plan as of January 1 (or new Medicare beneficiaries who are enrolled in an MA plan during their Initial Coverage Election Period) may enroll in another MA plan or disenroll from their MA plan and return to traditional Medicare.  Individuals may also add or drop Part D coverage during the MA OEP.  Only one election is allowed during this period and the effective date for election is the first of the month following receipt of the enrollment requests.  The MA OEP occurs from January through March 31 for individuals enrolled in an MA plan.  For new Medicare beneficiaries who are enrolled in an MA plan during their ICEP the MA OEP occurs the month of entitlement to Part A and Part B – the last day of the 3rd month of entitlement. 

Also note that the Special Enrollment Period (SEP) for individuals dually eligible for Medicare and Medicaid and those with the Part D low-income subsidy (LIS) will be changing from an open-ended monthly SEP to one that can be used only once per calendar quarter during the first nine months of the year (January through September).